Research Article Chronic Functional Constipation and Encopresis …downloads.hindawi.com/journals/grp/2016/7828576.pdf · 2019-07-30 · Research Article Chronic Functional Constipation

Research ArticleChronic Functional Constipation and Encopresis in Childrenin Relationship with the Psychosocial Environment

Claudia Olaru,1,2 Smaranda Diaconescu,1,2 Laura Trandafir,1,2

Nicoleta Gimiga,1,2 Radian A. Olaru,3 Gabriela Stefanescu,1,4

Gabriela Ciubotariu,1,2 Marin Burlea,1,2 and Magdalena Iorga1,2

1 “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania2“Sf. Maria” Emergency Hospital for Children, Iasi, Romania3“Socola” Emergency Hospital, Iasi, Romania4“Sf. Spiridon” Emergency Hospital, Iasi, Romania

Correspondence should be addressed to Smaranda Diaconescu; [email protected]

Received 14 July 2016; Accepted 25 September 2016

Academic Editor: Branka Filipovic

Copyright © 2016 Claudia Olaru et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Functional constipation is an issue for both the patient and his/her family, affecting the patient’s psychoemotional balance, socialrelations, and their harmonious integration in the school environment. We aimed to highlight the connection between chronicconstipation and encopresis and the patient’s psychosocial and family-related situation.Material andMethod. 57 patients with agesspanning from 6 to 15 were assessed within the pediatric gastroenterology ward. Sociodemographic, medical, and psychologicaldata was recorded. The collected data was processed using the SPSS 20 software. Results. The study group consisted of 57 childrendiagnosed with encopresis (43 boys (75.44%) and 14 girls (24.56%)),𝑀 = 10.82 years. It was determined that most of the childrencame fromurban families with a poor socioeducational status.We identified a level of studies of 11.23±5.56 years in mothers, whilefathers had an average number of 9.35 ± 4.53 years of study. We also found a complex relationship between encopretic episodesand school performances (𝐹 = 7.968, 𝑝 = 0.001, 95% Cl). Children with encopresis were found to have more anxiety/depressionsymptoms, greater social problems, more disruptive behavior, and poorer school performance. Conclusions. The study highlightsthe importance of the family environment and socioeconomic factors in manifestations of chronic constipation and encopresis.

1. Introduction

Functional constipation is characterized by infrequent stoolevacuation, passing of hard stools, or painful defecation withno fundamental organic cause [1]. Up to 84% of the childrenwith chronic constipation experience frequent episodes offecal incontinence [2]. Chronic constipation and secondaryfecal incontinence are a source of concern for the childand his/her family. The symptoms are often persistent andrelapses are frequent [3–5]. Fecal incontinence can alsocause feelings of guilt and discomfort and is associated withsocial withdrawal behaviors, anxiety, and depression [6–8].Encopresis is defined as a disorder characterized by repeatedstool evacuation in inappropriate places in children overthe age of four. The behavior can be either involuntary or

intentional; itmust be present for aminimumof threemonthsat a rate of at least once a month and is not the direct effectof a substance or a medical condition [9]. Biological anddevelopmentalmechanisms can be responsible in the etiologyof encopresis, and so can psychosocial and environmentalfactors. Many of the children presenting with encopresis haveexperienced a previous event that triggered the disorder bymaking the bowel movement uncomfortable or scary [10].Such an event can vary from constipation associated withpainful bowelmovement or fear of using the toilet to repeatedsexual abuse. The prevalence of encopresis was assessed inaround 1–3% of the general pediatric population [11, 12].Reports show that this rate is higher (4%) in developingcountries [13]. No encopresis-related studies were carriedout on the pediatric population in Romania [14, 15].The

Hindawi Publishing CorporationGastroenterology Research and PracticeVolume 2016, Article ID 7828576, 7 pageshttp://dx.doi.org/10.1155/2016/7828576

2 Gastroenterology Research and Practice

Table 1: Demographic characteristics, history, and clinical features of the patient series.

DemographicsAge (median) 10.82 (6–15)Sex (M) (𝑁/%) 43/57 75.44%Area of origin (urban) (𝑁/%) 34/57 59.65%HistoryFamily history of functional constipation (𝑁/%) 8/57 14.03%Time lapsed from the onset of symptoms (week) to the first medical consult (urban/rural) 7.8/11.7 (1–17)/(5–19)Duration of symptomatology (years) 4.21 (2–7)Average duration of treatment (months) 14 (6–32)SymptomsFrequency of defecation/week 1.32 (1–3)Encopretic episodes/month 28.3 (18–41)Urinary incontinence (𝑁/%) 9/57 15.78%Abdominal pain (𝑁/%) 34/57 59.64%Stool passing pain (𝑁/%) 46/57 80.70%

long-term results and factors influencing the prognosis aredebatable: while some studies reported behavior disordersand the family environment as predictors of poor outcomesin nonretentive encopresis, Montgomery and Navarro [16]and Van Wering et al. [17] described retentive encopresisas being negatively correlated with the favorable evolutionand risk factors could not be determined. The aim of thisstudy was to highlight the sociodemographic characteristicsof the encopretic patients and those of their families andthe occurrence of behavioral issues, as well as identify thedepressive and anxious disorders occurringwithin this group.For this purpose there was a focus on identifying the socialand family-related environment conditions by determiningthe level of education and current profession of the child’snext of kin, studying the changes in terms of somatizationand behavior in patients struggling with constipation, andestablishing some correlations between the severity of clinicalaspects and the psychosocial impact on both the patient andhis/her family.

2. Material and Method

The prospective cohort study was carried out on a groupof 57 patients and spanned on a period of 20 weeks. Thestudy included children aged 6 to 15 that were admitted tothe gastroenterology unit of a tertiary hospital from north-eastern Romania. The study included underage patients andtheir next of kin, who were informed in advance withregard to the purposes of the study and signed an informedconsent form prior to the inclusion. The inclusion criteriaare as follows: patients with at least one encopretic episodeper week, spanning over at least one year. The exclusioncriteria are as follows: documented mental retardation orany neuromuscular or gastrointestinal disorders associatedwith organic constipation, attention deficit/hyperactivity, orobsessive-compulsive disorders. Of all the 67 patients thatwere diagnosed with encopresis, 8 were excluded due to theparents’ refusal to participate in the study and 2 abandoned

the study during the assessment phase, with the final groupincluding a total of 57 patients. The medical history phaseincluded gathering information regarding the parents’ level ofeducation and their level of professional certification. We alsorecorded school-related data: education and training level,school results, absenteeism, and abandonment. For the pur-pose of assessing the clinical symptoms of encopresis, chil-dren and their parents were required to record the frequencyof such symptoms in a diary for a month. Laxative-basedtreatment was stopped during this month. To determinethe impact of encopretic disorders on the psychoemotionalbalance, all patients underwent psychological examinationby a clinical psychologist through observation, structuredinterview, the ASEBA scales [18], and projective tests. ASEBAscales were used to describe the child’s behavior. An assess-ment can quickly and effectively assess diverse aspects ofadaptive and maladaptive functioning (schizoid or anxious,depressed, uncommunicative, obsessive-compulsive, somaticcomplaints, social withdrawal, hyperactive, aggressive, delin-quent, sex problems, etc.). Interview and projective tests wereused to identify the personal beliefs and the impact of thedisease on daily life. Results were used also to build theindividual therapy.

3. Results

A total of 57 underage patients participated in the study. Thedemographic characteristics and medical data are describedin Table 1. Children were aged between 6 and 15 (median age10.82 ± 2.507) (Figure 1).

Of all the subjects, 75.44% (𝑁 = 43) were males and24.56% (𝑁 = 14) were females. The M : F ratio is 3.07 : 1. Asfar as the origin community is concerned, 59.65% came fromurban areas and 40.35% came from rural areas (Table 1).

68.42% (39/57) of children received treatment with orallaxatives 6months before the enrollment. Rectal enemas wereused at the beginning of the treatment as disimpaction ther-apy; 19.29% (11/57) of children were treated with oral laxatives

Gastroenterology Research and Practice 3

Normal

2

5

3

7

109

5 56

5

0

2

4

6

8

10

Num

ber

10 12 159 14114 7 135 1686Age

N= 57Std. dev. = 2.508Mean = 10.82

Figure 1: Distribution of patients according to the age.

and underwent dietary changes (fiber rich diet and toilettraining), and 12.28% (7/57) underwent dietary changes.Only7.01 (4/57) of the children went to a psychologist. All of themwere from urban areas. 12.28% (7/57) declared that they didnot follow the recommended treatment. 85.71% (6/7) werefrom rural areas.The frequency of encopretic episodes rangedbetween 18 episodes/month and 41 episodes/month, with anaverage of 28.3 ± 6.67.

As far as the social and family environment is concerned,14.03% (8/57) of the children were living in single parentfamilies, 19.29% (11/57) of the children had one parentworking abroad, and 7.01% (4/57) had both parents workingabroad and lived with their grandparents.

The study considered variables related to the parents’ levelof education, profession, and their addressability to medicalservices (the time from the onset of the symptoms to firstmedical consult). In terms of educational level, we noted that50% of the parents (𝑁 = 57) had finished middle school (8grades) and 15.78% (𝑁 = 18) completed professional studies,while 34.22% (𝑁 = 39) of the participants had completedsecondary or higher education (high school and universitydiplomas). Another variable we tracked was the number ofyears of study averaged by the parents. Thus we identified alevel of studies of 11.23 ± 5.56 years in mothers, while fathershad an average number of 9.35 ± 4.53 years of study. Theanalysis of current occupation and professional status showedthat the parents included in the study worked in variousfields: 48 workers, 23 intellectuals, 28 unemployed persons,and 15 people who retired for medical reasons. The ANOVAtest interpretation revealed that the number of encopreticepisodes per month was influenced by the level of educationof the patients’ female next of kin. (𝐹 = 2.684, 𝑝 = 0.008, 95%Cl) (Table 2).

Education-related data was collected during interviewswith the next of kin and conversations with the patient. Wequantified the level of education andnumber ofmissed schooldays within the studied group. Of the 57 children included in

Table 2: Encopresis frequency and relation with the level ofeducation of the patients’ female next of kin.

ANOVA frequency of encopresis/monthSum of squares df Mean square 𝐹 Sig.

Between groups 1055.652 12 87.971 2.684 .008Within groups 1442.278 44 32.779Total 2497.930 56

0

1

2

3

4

5

6

Cou

nt

36352924 2523 26 2722 3734 393818 282019 3130 33

Encopresis frequency (month)

School performanceDoes not go to school1-year failureDaily frequency

Figure 2: Distribution of patients according to school performanceand number of encopretic episodes per month.

Table 3: Frequency of encopretic episodes and relationship with theschool absenteeism.

ANOVA frequency of encopresis/monthSum of squares df Mean square 𝐹 Sig.

Between groups 569.178 2 284.589 7.968 .001Within groups 1928.751 54 35.718Total 2497.930 56

the group, 9 (15.78%) had abandoned school and 5 (8.77%)failed one year of study (Figure 2).

21 of the children had around 0–10 missed classes, 31children had around 11–40 missed classes, and 5 of them hada large number of missed classes, namely, around 41 and 100per semester. The ANOVA test interpretation revealed thatthe number of encopretic episodes per month influences thenumber of missed classes. (𝐹 = 7.968, 𝑝 = 0.001, 95% Cl)(Table 3), (Figure 3).

Psychological data were collected in order to shape apsychological profile for children with encopretic and consti-pation problems. The psychological evaluation identified (invarious associations) psychomotor agitation (𝑁 = 9; 15.79%),


Table 4: Psychological evaluation.

Psychological examination Number of cases PercentagePsychomotor agitation 9 15.78%Anxiety 22 38.59%Panic attack 1 1.75%Tic disorder 2 3.5%Affective deprivation 30 52.63%Social adjustment difficulties 13 22.81%Low average IQ 2 3.51%Negativism 7 12.28%Irritability, irascibility 6 10.52%Acute reaction to stress 1 1.75%Depressive syndrome 8 14.03%Shyness 12 21.05%Low tolerance to frustration 11 19.29%Speech disorders 5 8.76%Emotional distress 5 8.76%Hypochondriac tendencies 1 1.75%

Mea

n fre

quen

cy o

f enc

opre

sis (m

onth

)

25.0

27.5

30.0

32.5

35.0

37.5

0–10 absences 41–100 absences11–40 absencesAbsences

Figure 3: The average value of encopretic episodes’ frequenciescompared to the number of missed classes.

anxiety (𝑁 = 22; 38.59%), affective deprivation (𝑁 = 30;52.63%), social adjustment difficulties (𝑁 = 13; 22.81%),introversion (𝑁 = 12; 21.05%), low frustration tolerance (𝑁 =11; 19.29%), depressive syndrome (𝑁 = 8; 14.03%), speechdisorders (𝑁 = 5; 8.76%), and emotional distress (𝑁 = 19;33.31%) (Table 4).

4. Discussions

The average age in our group of patients with encopresis was10.82 years. The data resulting from this study were differentfrom other data in the literature, which indicate a higherprevalence in small children. A population-based studyconducted in the Netherlands which involved 13,111 parents

and their 5- to 6-year-old children and 9,780 parents andtheir 11- to 12-year-old children revealed that the prevalenceof encopresis was 4.1% in the 5-to-6 age group and 1.6% in the11-to-12 age group. Encopresis wasmore frequent among boysand children from the poorest areas of the city [19]. Similarresults were also discovered in the population of southeastNigeria. The authors of the study showed that encopresisaffected 3% of 4-year-old and 1.6% of 10-year-old children.It occurs more commonly in the 5- to 10-year-old groupand less frequently in adolescence, and it predominantlyaffects males [20]. Encopresis also occurs in adolescents andeven among adults; however, the prevalence is unknownin those age groups [21]. As far as gender distribution isconcerned, our results are consistent with the studies of theauthors mentioned above [19, 20]. The patients’ geographicarea of origin was predominantly urban. The low frequencyof patients from rural areas in our study could be a result ofdelayed diagnosis due to reduced access tomedical services insome disadvantaged communities, as well as the ignorance ofthe symptomatology by the patients’ next of kin with a lowerlevel of education. This idea is also supported by the fact thatthe average time lapsed from the onset of the disorder to thepatients’ seeing a doctor was longer in rural areas comparedto urban areas (11.7 weeks/7.8 weeks). A highlight in our studyis that only 59.7% of the patients lived with both parents.Children from broken homes can present a higher risk ofdeveloping emotional and behavioral disorders. Literaturedata confirms that the structure of the family into which achild develops entails some disadvantages that subsequentlyaffect cognitive, socioemotional, and even physical healthoutcomes. For example, high cognitive scores and less socioe-motional or health disturbances were registered in childrenwith married parents [22–24]. Time allocated to raising andcaring for children is expected to be positively correlated withtheir wellbeing [25]. While the quality of the time a parentspends with the child is important, studies have shown thatquantity of such time also has positive consequences for childcognition and health [26].This research points specifically tothe likely negative effects of paternal absence, results provedby other studies that identified that the absence of eithermother or father has great impact on children’s development[22, 27]. Changes in family structure are typically accompa-nied by changes in economic, time, and parental resources;these in turn place stress on families and thus adverselyaffect child outcomes. Family instability also yields residentialinstability and a sense of insecurity concerning householdrules, leading to an increased rate of behavioral problems, lowrate of cognitive achievements, and poorer health [22, 28–30]. In our study, most of the parents (65.78%) of childrenwith encopresis had a low educational level. The medicalhistory analysis highlighted that most of the children thatdid not observe the previous prescribed courses of treatmentcame from rural areas and their parents had a low level ofeducation (85.71%), while all the children that had seen apsychologist were from urban areas and their parents hadcompleted secondary or higher education. Considering thatthe treatment for encopresis is based particularly on theclose observance of therapeutic indications [31, 32], we canspeculate that parents with a higher level of education might


be more compliant. Parental education was reported both asa competence marker for toilet training and as a factor ofprotection against the stress of living in an underprivilegedfamily [33]. In our study, children whose mothers had ahigh educational level reported a lower number of encopreticepisodes per month (𝐹 = 2.684, 𝑝 = 0.008, and 95% Cl). Animportant question is whether the frequency of encopreticepisodes influences school performances. The analysis onthe rate of enrollment, school absenteeism, and the chil-dren’s capacity to complete the academic year showed thatchildren with encopresis have learning disabilities and poorschool performances and miss school days more frequently.Lower rates were registered for scales measuring spellingand arithmetic skills using Wide Range Achievement Test(WRAT), as Stern et al. identified [34, 35]. The relationshipbetween health status and academic achievement is morecomplex than it would seem at first glance. While there isstrong evidence that children whose healthcare needs aremet are less likely to miss school days because of illness,school performance is multidetermined. These risk factorsinclude parental attitudes and beliefs, patterns of mother-child interaction, maternal education, socioeconomic status,family social support, family size, stressful life events, andthe child’s cognitive functioning. It was proved that thereare psychosocial factors which affect academic outcomes aswell as emotional development. Children exposed to thesefactors are at heightened risk for emotional and behavioralproblems and school failure [36]. Children in homelessfamilies experience a high rate of academic failure consistentwith the need for special education evaluation and services[37].

Encopretic children are a particularly vulnerable socialgroup, being exposed to social risks in terms of losingtheir sense of belonging both to their own generationgroup and the entire society, reaching a marginal positionin society. Stigmatized by parents, peers, neighbors, andsociety, encopretic patients have fragile personalities thatneed tolerance, intercommunication, and a lot of trust fromother people. Several authors have reported finding poorerself-esteem in children with encopresis. Low scores regardingself-esteem were identified by Landman et al. in childrenwith encopresis, comparing to a control group formed bychildren with chronic physical problems [34, 38]. Lower self-esteem in encopretic children than in nonsymptomatic oneswas also reported by Owens-Stively [34, 39]. The most fre-quent changes encountered in our study included emotionaldistress, anxiety, and social adjustment difficulties. Therewas a high rate of somatization and behavioral disorders inour group and their composition was largely heterogeneous.Literature data shows that the association of encopresis withbehavioral disorders has led to an unfavorable prognosis ofthis disorder [40, 41]. Levine et al. found that children withencopresis who did not respond to treatment scored higheron antisocial-aggressive behaviors before treatment [42].They also reported differences between a nonsymptomaticcomparison group and the children with encopresis prior totreatment on affective-dependent behavior (i.e., those whodemonstrated signs of anxiety and depression). In a studyby Johnston and Wright, attention deficit or hyperactivity

was identified for 23% of cases of encopretic children [43].A number of studies have demonstrated poorer social skillsand higher withdrawal behavior in children with encopresis[42, 44].

Some authors believe that, in predisposing to and per-petuating encopresis, the approach of toilet training, not thetime of its initiation, seems to be the factor that matters[45]. Regarding the psychological treatment, attention andbehavior problems may be the target. Treatment of theseproblems may increase treatment compliance and preventconflicts that may occur within the family in relation tothese problems because a lot of studies pointed the impactof child behavior related to family conflicts [46–48]. Onthe other hand, familial factors such as maternal depressionand/or anxiety symptoms are associated with eliminationdisorders at school age and including factors related tofamily functioning must be included in the psychologicalintervention [49].

Our study has some limitations. This is a single centerreport and is limited to children addressed to our gastroen-terology center. It is not clear whether the results would holdfor a nationally representative sample of children in Romania.Because the period covered by the study was also relativelyshort, it is not clear whether the disparities between childrenof parents with more or less education remain as children ageand how they affect a larger set of outcomes.

Our analysis leaves many questions for future research.The behavioral disorders noticed in children with encopresiscould be either a result of their excessive concern withuncontrollable encopretic accidents and the resulting socialtension or a result of some developmental delays that couldultimately play a part in the development or persistenceof encopresis. Another critical question is the extent towhich specific policies and programs dedicated to childrencan help address the observed deficits (improvement ofaccess to health care services and various means of cognitivedevelopment). Future research is necessary in this direction.

5. Conclusions

The findings of this study allow us to outline a profile ofencopretic patients with respect to some of the psychosocialfactors involved in the multifactorial determinism of thisdisorder. Educating parents on the association with somati-zation and behavioral disorders can lead to a more effectivediagnosis and a better response to treatment for children withconstipation and fecal incontinence. Screening for behavioraldisorders in encopretic patients could be useful for theirtherapeutic management. A more aggressive treatment forconstipation can be justified in these patients. In the casesthat associate severe behavioral disorders, early diagnosis andmultidisciplinary therapeutic approach can be useful for boththe child and families.

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this article.


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